When Medicine Was Cheap

On December 14, 1799, George Washington died—most likely, modern experts believe, from something called acute epiglottitis. His death wasn’t due to any lack of effort on the part of his doctors: they gave him an enema, covered his feet and legs with a wheat-bran poultice, applied a salve and a “preparation of dried beetles” to his throat, and bled him almost dry—about five pints, nearly half the blood in his body, drawn in less than a day.

The medical team that treated Washington was a good one, but, as Bill Schutt observes in his book “Dark Banquet: Blood and the Curious Lives of Blood-Feeding Creatures,” the doctors still came in for criticism after their patient’s death:

One physician claimed that Washington’s tonsils should have been scarified, while another suggested that the former president’s doctors should have bled him from under the tongue, since that location was anatomically closer to the problem. Other suggestions included rubbing Washington’s throat with “warm laudanum” (a mixture of alcohol and opium) and, following this, the application of a bag of warm salt to his neck…. Some insisted that he should have been urged to drink small portions of hot whey, laudanum, or spiritus volatilis aromaticus, a mixture of ammonia, carbonate of potash, cinnamon, cloves, and lemon peel.

It’s easy to forget how far we’ve come, and in how short a period of time, even as the Supreme Court hears arguments over the Affordable Care Act. There is no mention of health care, or how to pay for it, in the Constitution, because for the men who wrote it health care wasn’t worth paying very much for. It remained that way until relatively recently. The science of medicine didn’t begin to resemble what we know today until the late nineteenth century. Until about 1900, many American medical schools were no better than the shadier for-profit colleges of today. In “The Great Influenza,” John M. Barry writes that at the time “it was more difficult to get into a respectable American college than into an American medical school…. Many schools bestowed a medical degree upon students who simply attended lectures and passed examinations; in some, students could fail several courses, never touch a single patient, and still get a medical degree.”

Health care had advanced enough in the early twentieth century that the first group health-insurance policy in the U.S.—one with a level of coverage that’s meager by our standards—was started in 1929. But the true miracles of modern medicine didn’t really come into being until the Second World War and after. Chemotherapy wasn’t discovered until the nineteen-forties. Penicillin first came into real use as part of an effort by the Allies to produce it for their soldiers, and wasn’t available for widespread civilian purposes until after the war. The first open heart surgery took place in the early nineteen-fifties. Even the more mundane procedures took some time to get right. One study covering the years from 1958 to 1973 found that the mortality rate of acute epiglottis was still thirty-two per cent, almost two hundred years after Washington died from it; today, that mortality rate is down to about seven per cent.

The sudden development of a truly life-saving science has forced us to grapple with a difficult question: If we have the power to save someone’s life, but they can’t afford to pay, do we stand aside and watch them die? As a society, we’ve essentially decided we won’t, and that, at least to a point, we’ll pay when they show up in the emergency room. (Often, the cost will be much higher than if we’d been willing to pay for preventive care.) But without a rational system in place to deal with those costs, which are quite high now that health care is worth paying for, we’ll bankrupt ourselves.

That problem is, in part, what the Affordable Care Act was supposed to deal with. It’s not the prettiest solution, but it’s a solution, and perhaps the only one that was feasible when so much of the legislating about health care in the U.S. seems to operate on a “this far, but no further” principle, where “this far” is “just enough to create new problems of its own” and “further” is “something that might actually work.” Unfortunately, it’s not possible to tell yet whether the justices fully grasp the implications of everything they’ve been considering for the past week. Brookings Institution senior fellow Henry J. Aaron observed,

Several of the justices, notably Scalia and Alito, responded to the externalities argument by saying that every economic transaction creates similar externalities. “If I don’t buy a Volt, I raise the price of Volts,” said Scalia. Alito said much the same thing. So did Paul Clement’s brief for the plaintiffs.

This response was and is bad economics. It is true that every commodity is produced along what economists call a “cost curve”—raising output may lower average or marginal unit costs by spreading overhead or achieving economies of scale, but it may also raise costs by forcing up the cost of inputs or incurring diseconomies of scale. None of this occasions concerns about fairness or free-loading or, to use the economist’s term, “externalities.” But the cost shifting that occurs when uninsured patients fail to pay their bills does; it causes one group—the insured—to have to pay part of the cost of services others use.

Hence the individual mandate. The mandate might not have been anyone’s dream policy, but it was what was politically possible, and it made the Act’s protections for those with preëxisting conditions work. After all, if I don’t have insurance, but can sign up for it as soon as I find out I need major surgery, then that’s not insurance, it’s a Groupon—four hundred dollars for twenty thousand dollars worth of surgery. Someone has to make up the difference. As Justice Elena Kagan, who was Obama’s Solicitor General during the floor fight over the A.C.A., put it during discussions Wednesday about whether the whole Act can stand if the mandate is struck down,

Once you say that the insurance companies have to cover all of the sick people and all of the old people, the rates climb. More and more young people and healthy people say, “Why should we participate? We can just get it later when we get sick.” So they leave the market, the rates go up further, more people leave the market, and the whole system crashes and burns, becomes unsustainable.

Yet now the mandate might prove to be the undoing of the A.C.A. It’s a bitter irony for Democrats who’ve been pushing health-care reform for decades: Justice Anthony Kennedy seemed to suggest on Tuesday that the single-payer system of liberals’ dreams, which of course is politically unfeasible, would be constitutional. But the politically feasible solution—the one that was originally a conservative idea, put into practice by the leading contender for the Republican Presidential nomination—might not be.

That raises another question. We’re dealing with issues, literally, of life and death, complicated questions that arose a hundred years after the Constitution was ratified. If the Court can’t come to terms with the law in a way that reflects political and modern medical realities, and our politicians can’t do so in a way that passes constitutional muster, who is most at fault?

Photograph by Bettmann/Corbis.

Alex Koppelman was a politics editor for newyorker.com from from 2011 to 2013.